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Waiting Time and Elective Surgery Access Policy

Managing Elective Surgery patients in ACT public hospitals

DGD16/015 Issue date: July 2016

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register


CONTENTS

1 INTRODUCTION..............................................................................................................3

2 REFERRING PATIENTS FOR ELECTIVE SURGERY....................................................8

2.1 Elective Surgery Categorisation........................................................................................9

2.2 Re-classification of the Clinical priority Urgency Category...............................................9

2.3 Excluded Procedures......................................................................................................10

2.4 Completion of the Request for Admission Form (RFA)..................................................13

2.5 Submitting a RFA............................................................................................................13

2.6 Processing a RFA...........................................................................................................14

2.7 Listing Date.....................................................................................................................14

2.8 Variations from Standard Bookings................................................................................15

3 MANAGING PATIENTS ON THE WAITING LIST..........................................................16

3.1 Calculating Waiting Times..............................................................................................16

3.2 ‘Treat in turn’..................................................................................................................16

3.3 Clinical Review................................................................................................................17

3.4 Ready for Surgery (RFS)................................................................................................18

3.4.1 Delayed Patients.............................................................................................................18

3.4.2 Declined Patients............................................................................................................18

3.5 Not Ready for Surgery (NRFS).......................................................................................18

3.5.1 Not Ready for Surgery – Staged Patients.......................................................................18

3.5.2 Not ready for surgery – Pending Improvement of Clinical Condition..............................19

3.5.3 Not Ready for Surgery – Deferred for Personal Reasons..............................................20

3.6 Admission Process.........................................................................................................21

3.7 Hospital Initiated Postponement (HIP)............................................................................22

3.8 Patient Initiated Postponement:......................................................................................23

3.9 Reporting of Hospital Initiated Postponements (HIPs)...................................................24

4 DEMAND MANAGEMENT..............................................................................................24

4.1 Demand Management Escalation...................................................................................25

4.2 Transferring Patients to another Facility for surgery.......................................................25

4.3 Removing Patients from the Waiting List........................................................................26

5 RECORD KEEPING.......................................................................................................28

5.1 Postponement of Planned Admission.............................................................................28

Doc Number Version Issued Review Date Area Responsible Page

DGD16-015 3.0 July 2016 July 2019 TWSS 1 of 63


5.2 Removal of Patients from the Waiting List (other than admission).................................28

6 AUDITING THE WAITING LIST......................................................................................29

6.1 Clerical Audit......................................................................................................................29

6.2 Request for Admission (RFA) Audit................................................................................29

7 DOCTOR’S LEAVE – TEMPORARY OR PERMANENT................................................30

7.1 Resignation, Retirement or Sudden Death.....................................................................31

8 DEFINITIONS.................................................................................................................32

9 APPENDICES.................................................................................................................40

Appendix 1 - Patient Notification Letter.....................................................................................40

Appendix 2 – Audit letter...........................................................................................................41

Appendix 2 – Audit letter...........................................................................................................42

Appendix 3 - Removal from Waiting List Letter.........................................................................43

Appendix 4 – Reclassification of Clinical Priority form..............................................................44

Appendix 5 – Notification to patient of Registration on the waiting list......................................45

Appendix 6 – Urgency Category outside National Guidelines..................................................46

Appendix 7 – Letter to GP advising of patient who smokes......................................................47

Appendix 8 – GP Notification Letter..........................................................................................48

Appendix 9 – Minimum Data Set Incomplete............................................................................49

Appendix 10 – Paediatric Notification Letter.............................................................................50

Appendix 11 – Excluded Procedure notification........................................................................51

10 REFERENCES...............................................................................................................52

11 ACRONYMS...................................................................................................................53

12 NATIONAL ELECTIVE SURGERY URGENCY CATEGORY GUIDELINE....................54

CARDIO THORACIC SURGERY...................................................................................54

OTOLARYNGOLOGY HEAD AND NECK SURGERY...................................................54

GENERAL SURGERY....................................................................................................56

GYNAECOLOGY SURGERY.........................................................................................57

NEUROSURGERY.........................................................................................................58

OPHTHALMOLOGY SURGERY....................................................................................59

ORTHOPAEDIC SURGERY...........................................................................................60

PAEDIATRIC SURGERY................................................................................................61

PLASTIC & RECONSTRUCTIVE SURGERY................................................................62

UROLOGICAL SURGERY..............................................................................................63

VASCULAR SURGERY..................................................................................................64




1 INTRODUCTION

Each year approximately 12,000 people from the Australian Capital Territory (ACT) and the surrounding region have elective surgery as patients of the ACT public hospital system.

Surgery is defined as procedures listed in the surgical operations section of the Commonwealth Medical Benefits Schedule. Surgery is classified as either emergency surgery, elective surgery or other surgery on the basis of a patient’s presentation and subsequent care.

Emergency surgery is defined as surgery to treat trauma or acute illness subsequent to an emergency presentation. The patient may require immediate surgery or present for surgery at a later time following this unplanned presentation. This includes where the patient leaves hospital and returns for a subsequent admission. Emergency surgery also includes unplanned surgery for admitted patients and unplanned surgery for patients already waiting for an elective surgery procedure (for example, in cases of acute deterioration of an existing condition).

Elective Surgery is defined as planned surgery that can be booked in advance as a result of a specialist clinical assessment resulting in placement on an elective surgery waiting list.

Other surgery is where the procedure cannot be defined as either emergency surgery or elective surgery, for example, transplant surgery and planned obstetric procedures.

Elective surgery in the public hospital system is provided through the use of waiting lists, which are registers of patients who are waiting for elective care. Patients are placed on a waiting list and assigned to a clinical priority urgency category depending on the seriousness of their condition. Clinical priority urgency categories 1, 2, and 3 referred to in this document are consistent with the National Elective Surgery Urgency Category guidelines developed in conjunction with the Australian Institute of Health and Welfare (AIHW) and the Royal Australian College of Surgeons (RACS) to enable improved consistency and reporting of elective surgery.

The capacity of the public health system to provide elective surgery is influenced by a number of crucial factors. These include the demand for emergency surgery, demand for the surgical specialty, demand for hospital beds due to emergency and urgent medical care, the supply of surgeons, anaesthetists and nursing staff, theatre capacity, scheduling and management practices, and effective discharge planning of patients from hospital.

Managing elective surgery and waiting lists is a key priority for the ACT Government and ACT Health. The community insists on transparency and accountability and patients expect timely, accessible and high quality patient-centred services. Failure to comply with ACT Health Policy may form part of ongoing divisional and/or individual performance reviews.




Hospitals have a responsibility for ensuring compliance with the contents of this document, and that processes are in place to:

Implement the framework Identify staff roles and responsibilities Validate the accuracy and integrity of reported data Regularly review individual hospital performance against Locally and Nationally set key

performance indicators Train and educate staff managing elective surgery and the waiting lists

The framework seeks to:

Support active management of patients waiting for elective surgery Support best practice in elective surgery waiting list management Identify the rights and responsibilities of hospitals, referring surgeons and patients Improve communication among patients, hospitals, referring surgeons and community

providers Support meaningful reporting to the public by hospitals and the government

The following principles underpin the Policy:

Referrals for elective surgery are clinically appropriate and are representative of a suitable treatment for the patient’s condition

Patients are provided with easy to understand information about access to elective surgery and their rights and responsibilities

Public patients are the shared responsibility of the hospital, the referring surgeon and the relevant specialty

Patients waiting for elective surgery are fully informed about, and have consented to the procedure/treatment

All documentation is complete, legible and accurate Waiting list management services are provided in an efficient, transparent and patient-

centred manner The elective surgery waiting list is managed to ensure patients are treated equitably

within clinically appropriate timeframes and with priority given to patients with an urgent clinical need

The scheduling of surgery is undertaken in consideration of available capacity Hospitals minimise the impact and inconvenience to patients whose surgery they

postpone The elective surgery waiting list is managed to promote the most effective use of

available resources Patients are categorised in accordance with National Elective Surgery Urgency Categories There is valid, reliable and accountable reporting of access to elective surgery




RESPONSIBILITIES

Responsibilities of the Patient:

Follow the procedures and advice outlined in the information provided Advise the hospital of any change in desire to undergo the procedure/treatment Follow hospital admission procedure and advise of any changes to the proposed

admission, such as availability or change of address or other contact details Attend any preadmission appointments as required and present on the day of admission

Responsibilities of the General Practitioner (GP):

Arrange referral for patients to a hospital that has surgeons with the appropriate expertise and the least waiting time for the anticipated surgical procedure (outpatient waiting time and travelling time should also be considered)

Provide the hospital with appropriate health information and personal details of the patient with referral

Liaise with the referring surgeon if there is a change in any indications for surgery or a change in patient’s health that may have implications for surgery and treatment

Responsibilities of the Surgeon or delegate (Registrar):

Explain the proposed procedure/treatment, options for treatment and potential complications and the anticipated length of stay, using an interpreter if required.

Explain that the procedure may be performed by another surgeon and/or another hospital

Consent forms are to be completed and signed by the surgeon and patient contemporaneously

If consent is provided by the person prior to their current admission, they are to have their consent reconfirmed on the ward or in the Surgical Admissions Area prior to transfer into the theatre suite. The staff member confirming consent will need to ensure that the person signs the confirmation of consent part of the Consent to Treatment form as part of this process

Assign a clinical priority urgency category for the procedure/treatment using the National Elective Surgery Urgency Category guidelines

If a patient is classified as staged, the time interval when the patient will be ready for surgery should be indicated

Ensure that Request For Admission (RFA) forms are legible and the minimum data set is completed

Forward completed RFA’s directly to the Central Wait List Service within 5 working days of signing and dating the RFA

Initiate prompt and appropriate communication with the referring GP regarding the proposed management of the patient

Referring doctors should ensure that they are able to perform the patient’s surgery within the clinical priority urgency category timeframe that they assign (excepting patients who may require multimodality therapies as parts of their treatment plan e.g.




some colorectal surgery). The referring doctor should advise the relevant hospital executive if they are unable to provide the service and discuss an appropriate management plan for the patient. As a result doctors should not submit category one RFA’s when they will be away during that period, unless they have pre-discussed a management plan with the relevant hospital. Such RFA’s will be returned to the surgeon to make such plans. Referring doctors must advise patients of their current waiting time for surgery if added to their elective surgery waiting list. This ensures the patient is informed about their approximate wait time and can make an informed decision regarding their care that may include proceeding with the referring surgeon, being referred to another surgeon and/or exploring other options such as utilising private health insurance. All clinicians are provided with their Wait List on a quarterly basis. This information will enable the clinician to provide patients with an accurate estimation of their current waiting times

Review the waiting list and verify with the hospital Inform patients if a RFA is not accepted and the patient not placed on the elective

surgery waiting list

Responsibilities of the Central Wait List Office:

Comply with local procedures/protocols for administrative processes that support this Policy

Ensure all documentation and electronic data input is accurate, legible and complete Ensure procedures included in the excluded list of procedures are not added to the

waiting list without approval from the Director – Territory Wide Surgical Services

Responsibilities of the Surgical Booking Office:

Comply with local procedures/protocols for administrative processes that support this Policy

Undertake all relevant audits to ensure all documentation and electronic data input is accurate, legible and complete

Assist in planning for patients surgery and patient notification for surgery and pre-admission appointments

Review and management of all patients listed on the elective surgery waiting list




Responsibilities of the Clinical Director of Surgical Services (TCH) / Director of Medical Services (CHC):

Ensure clinician compliance with this Policy Promote efficient and effective waiting list management by clinicians within their hospital Liaise with the Director - Territory Wide Surgical Services for escalation of any issues

Responsibilities of the Director of Territory Wide Surgical Services:

Provide advice on Territory wide issues relating to surgery Review and manage applications to perform excluded procedures Promote compliance with this Policy Act as an adjudicator for issues that require resolution




2 REFERRING PATIENTS FOR ELECTIVE SURGERY

All patients referred for an elective surgery procedure must have a RFA form completed. The RFA and consent to treatment forms, located in the Planned Hospital Admission Booklet for Surgical and Medical Care, will only be accepted if completed by Consultant Clinicians and Registrars currently contracted to ACT Health, and appropriately credentialed with the Medical and Dental Appointments Advisory Committee and the respective hospital.

The referring surgeon must:

Complete an approved RFA Form ensuring the minimum data set is complete, legible and accurate

Assign a clinical priority urgency category consistent with the National Elective Surgery Urgency Category guideline and provide a clinically verifiable reason to assign a different category (if required)

Ensure patients are fully informed about the risks and benefits of the procedure and have consented to the treatment offered1

Consent to be completed by the surgeon performing the surgery or his delegate e.g. Registrar

If consent is provided by the person prior to their current admission, they are to have their consent reconfirmed on the ward or in the Surgical Admissions Area prior to transfer into the theatre suite. The staff member confirming consent will need to ensure that the person signs the Confirmation of Consent part of the Consent to Treatment form as part of this process

Ensure patients are ready for surgery and ready to accept a surgery date Forward the completed RFA to the Central Wait List Service within 5 working days of

signing the RFA Ensure the RFA is signed and dated on page 4 Inform patients that while generally public patients will be admitted under the care of

the referring surgeon, this is not guaranteed Inform patients that the location of their surgery can vary and they will be allocated a

surgery site appropriate to their surgical requirements Ensure that they are able to perform the patients surgery within the clinical priority

urgency category timeframe that they assign (excepting patients who may require multimodality therapies as part of their treatment plan e.g. some colorectal surgery)

If a RFA is presented for a procedure(s) a surgeon is unable to perform, for any reason, the RFA is not to be added to the surgeons’ waiting list and should be returned to the doctor’s rooms as soon as possible

Inform the patient of an approximate waiting time for surgery

2.1 Elective Surgery Categorisation

1 CHHS Consent and treatment policy 2016 (CHHS16/026)




Categorisation of elective surgery patients is prioritised by clinical urgency and is required to ensure patients receive care in a timely and clinically appropriate manner. A clinical urgency priority is assigned by the referring surgeon using the National Elective Surgery Urgency Categories as a guide. Categories assigned outside the guidelines must have a clinically verifiable reason documented in the section provided on the RFA. RFAs received with a clinical priority urgency category outside of the National Guidelines and no documentation of a clinically verifiable reason will be added to the elective surgery Wait List in accordance with the National Guidelines. The Specialist Surgeon will be notified by letter (Appendix 6) that this has occurred. If a clinically verifiable reason exists for allocation to a higher/lower category, the Specialist Surgeon will be required to submit a re-categorisation form for processing within 7 days stating the clinically verifiable reason for change.

Elective Surgery is categorised into the following 3 categories which are defined as:

Category 1: Procedures that are clinically indicated within 30 days.Category 2: Procedures that are clinically indicated within 90 days.Category 3: Procedures that are clinically indicated within 365 days.

2.2 Re-classification of the Clinical priority Urgency Category

Re-classification of a patients assigned clinical priority urgency category to higher category (eg category 2 to category 1) must only occur following a clinical assessment/review of the patient by a medical officer and reflect a change in the patient’s condition that has occurred after the patient has been added to the elective surgery waiting list. This review could be done by phone for some patients, but patients should be offered a face to face assessment if they so desire, and clinically practicable.

Reclassification to a lower category (category 1 to category 2) the patient must be directly informed by the clinician, and reasons given to the patient.

Re-classification cannot occur following a review of clinical notes only, but can occur following receipt of investigative results that indicate a deteriorating, or improving condition.

Re-classification is independent of the outlined processes related to the National Elective Surgery Urgency Category Guideline when a patient is first added to the elective surgery waiting list.

Re-classification must not be used to facilitate ‘on time’ surgery when difficulties in scheduling may arise.

Authority to reclassify a patient’s clinical priority urgency category may only be undertaken by the Consultant or Delegate, who must complete the reclassification of clinical priority form, stating a clinical reason for the change. The clinical reason for the change may reflect deterioration in the patient’s condition or an improvement/reassessment of the patient’s condition. The re-classification will not be processed if a form is not completed or the form is incomplete.




Documentation of a re-classification must be recorded in the patient electronic record (ACTPAS) giving the reason for the change. Patients must be advised of any change in their clinical priority urgency category and a brief summary of the telephone conversation recorded in the patient’s electronic record.

Should the referring surgeon complete a new RFA form assigning a new clinical urgency category, this can only be accepted if the patient has signed the consent form or there is evidence that a clinical review/assessment of the patient has occurred.

If the new RFA has a different principle procedure listed, the original waiting list entry should be removed as ‘procedure no longer required’. The new RFA is then logged onto the elective surgery waiting list with the new procedure listing date being backdated to the original listing date.

If the new RFA has a minor change to the procedure, i.e. the principle procedure remains the same, the wait listing entry should be amended and the new RFA attached to the original RFA.

Documentation of the changes must be recorded in ACTPAS.

The Territory Wide Surgical Services Team will conduct monthly audits of all re-classifications of clinical urgency and maintain records of the audit results for reporting as required to hospital management and to the Surgical Services Taskforce.

2.3 Excluded Procedures (Cosmetic and Discretionary)

Surgery should meet an identified clinical need to improve the physical health of the patient.

The following list of surgical procedures should not be performed in public hospitals in the ACT. For procedures not appearing on the list below that could be interpreted as cosmetic in nature, the RFA should be referred to the Director Territory Wide Surgical Services for review prior to the patient being added to the elective surgery waiting list.

Excluded Procedures Exception

Reduction mammoplasty Gross breast asymmetry in patients under 21

Virginal Hyperplasia/Hypertrophy

Breast augmentation Nil

Replacement breast prosthesis Replacement for post cancer patients only

Hair transplant NilBlepharoplasty 1. Vision obscured as evidenced by

upper eyelid skin resting on lashes on straight ahead gaze




Excluded Procedures Exception2. Herniation of orbital fat in

exophthalmos3. Facial nerve palsy or post traumatic

scarring4. Restoration of symmetry of

contralateral eyelid in respect of one of the above conditions

Total rhinoplasty – Cosmetic only Functional/traumatic/congenital

Liposuction (cosmetic only) Nil

Abdominal lipectomy (Abdominoplasty) Nil

Facelifts / Meloplasty Nil

Correction of bat ear (>16 years old) Nil

Tattoo removal procedures Nil

Removal of benign moles, skin tags, revision of scar, removal of keloid scarring, removal of sebaceous cyst, or any skin abnormality deemed to be wholly aesthetic in nature

Nil

Candela Laser Congenital abnormality – paediatrics < 17 years

Skin laser photocoagulation Nil

Reversal of sterilisation Nil

Circumcision without medical indication Phimosis, paraphimosis, balanitis, Frenulum breve

Bariatric Surgery Only referred from the Obesity Management Service

Varicose Veins CEAP Grade >2

Reproductive Organ Surgery

Insertion of artificial erection devices Nil

Gender reassignment surgery Congenital abnormalities in children

Phalloplasty Congenital abnormalities in children

Labioplasty Nil




There may be instances where the Medical Officer wishes to apply for an exemption to the exclusion list or other cosmetic procedure. The Medical Officer must include with this application verifiable clinical evidence to support this application. For example, a patient requesting breast reduction or abdominoplasty for severe intertrigo will need a letter from a dermatologist stating this procedure is clinically required to improve this patient’s health after failure of medical therapy, or documented evidence of two admissions to hospital for treatment of cellulites.

If a patient requests an excluded procedure for alleviation of significant psychiatric symptoms a letter from a Psychiatrist will need to be included with the outpatient department referral stating this procedure is required to improve the patient’s mental state. Similarly, if a patient is requesting an upper or lower eyelid Blepharoplasty the Medical Officer must document one of the following rationales on the RFA or supply photographic evidence.

1. Vision obscured as evidenced by upper eyelid skin resting on lashes on straight ahead gaze

2. Herniation of orbital fat in exophthalmos3. Facial nerve palsy or post traumatic scarring4. Restoration of symmetry of contralateral eyelid in respect of one of the above conditions

This application must be forwarded to the Director, Territory Wide Surgical Services (TWSS) ([email protected]) for review and endorsement. If, on the evidence supplied, the Director TWSS endorses the application, the referral/request would then be forwarded to the relevant hospital Surgical Director for final endorsement following assessment at the hospital site to determine the capacity to undertake the procedure. It must be stressed the occasions for acceptance to undertake an excluded procedure would be rare, and patients should be counselled that there is no guarantee that exception to the excluded criteria provisions would be granted.

This policy does not include gender reassignment procedures for which there are no exceptions (adults), nor breast reduction for back pain.

New Procedures

The Health Technologies Assessment Committee must formally approve new procedures not previously undertaken. Clinicians must also be appropriately accredited to undertake the procedure before patients are added to the elective surgery waiting list. A doctor may only refer patients for addition to the elective surgery waiting list for procedures when the clinician has been accredited by Medical and Dental Appointments Advisory Committee. Surgical procedures should only be conducted at the hospital by an appropriately skilled clinician and where the infrastructure exists to enable the proposed procedure to be performed.



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2.4 Completion of the Request for Admission Form (RFA)

The following minimum data set on the RFA Form is to be obtained by the Referring Doctor:

Patient’s full name Patient’s address Patient’s contact information (home, work & mobile telephone) Patient’s gender Patient’s date of birth Medicare number Clinical priority urgency category and a clinically verifiable rationale if required If classified as staged, the time interval when the patient will be ready for surgery

should be indicated. The category selected should reflect the time window of when the surgery is to be performed.

Discharge intention (i.e. day only, or indication of number of nights in hospital) Presenting problem Planned procedure/treatment Estimated operating time Treating doctor (if different) General Practitioner’s name and address Doctor to sign and date the RFA on page 4

Other relevant information should be included on the RFA that may include: Significant medical history Specific preadmission requirements Special operating theatre equipment Requirement for an ICU/HDU bed post procedure

2.5 Submitting a RFA

Completed RFAs must be submitted directly to the Central Wait List Service (CWLS) within 5 working days of RFA being signed and dated on page 4, either via secure email or for collection by the courier.

RFAs for urgent category one patients requiring surgery within 7 days can be taken directly to the Surgical Bookings Office (SBO) at the hospital site or emailed as URGENT to the Central Wait List Service. A confirmation email will be sent on receipt of the RFA.




2.6 Processing a RFA

All RFAs will be date stamped on receipt and the patient registered on ACTPAS. Category 1 RFAs will be managed as a priority. Category 2 and 3 RFAs will be processed differently.

Category 1 patients

Urgent Category 1 RFAs (less than 7 days to surgery) may be submitted to the Central Wait List Service or the surgical bookings office. Alternatively, emailed RFAs ‘flagged’ as urgent Category 1 can be sent directly to the Central Wait List Service. Central Wait List Service nursing staff will contact the patient by phone and conduct a health assessment and obtain any other relevant health information from other health professionals. The Central Wait List Service Nurse will contact the Elective Surgery Liaison Nurse (ESLN) and discuss the case, including surgery requirements and the patient’s readiness for surgery. Patients will be added to the Elective Surgery Waiting List (ESWL), with an auto-generated letter from ACTPAS sent to the patient and General Practitioner. All information will then be sent to the ESLN and the Medical Records Department for scanning into CRIS.

Category 2 & 3 patients

Following registration in ACTPAS, an administrative check will be conducted and patients sent a letter stating their paperwork has been received. A Patient Health Questionnaire (PHQ) will also be sent to the patient for completion and return in the reply paid envelope. Patients will be advised they will not be processed onto the ESWL until after their PHQ is returned. Nursing staff will have processes in place to monitor the return of these forms. Patients who have a PHQ sent to them by mail will have their ESWL listing dated as the date the RFA was accepted (see below “acceptance”), not the date the PHQ is received; when returned.

Nursing staff will review the patient information and obtain any relevant health information from other health professionals and raise any significant issues with the Elective Surgery Liaison Nurses at the hospital site. Patients will then be added to the ESWL, and an auto-generated letter from ACTPAS sent to the patient and GP. All information will then be sent to the surgical bookings office and Medical Records Department for scanning into CRIS.

2.7 Listing Date

A patients listing date will be the date the RFA is accepted. The acceptance date can be the same as the received date “Acceptance” will be deemed when the following are complete:-

The minimum RFA data set is completed The RFA form is signed and dated on page 4 It is not an excluded procedure It is within National Elective Surgery Urgency Category (ESUC) guidelines, or a

clinically verifiable rationale is documented supporting the change in category




The surgeon is available and able to provide the patient with a date for surgery within the clinical priority urgency category timeframe that they assign (excepting patients who may require multimodality therapies as part of their treatment plan e.g. some colorectal surgery)

Patients should be placed on the electronic elective surgery waiting list within 3 working days of acceptance of a completed RFA

RFAs received 3 months or more after being signed and dated by the referring surgeon will not be accepted and will be returned to the referring surgeon for review. RFAs not accepted will be returned to the referring surgeon accompanied by a letter explaining the reason for return. It is the referring surgeon’s responsibility to progress any further action required and inform the patient should they not be placed on the elective surgery waiting list for a procedure.

2.8 Variations from Standard Bookings

Procedure/treatment not provided - if a procedure/treatment is not provided at the hospital nominated on the RFA, the RFA cannot be accepted. The referring doctor should be informed and alternative arrangements negotiated with senior management before accepting a revised RFA.

New Procedures - The Health Technologies Assessment Committee must formally approve new procedures. The RFA is not to be accepted by the hospital until approval for the procedure is given. A copy of the decision is to be forwarded to the hospital’s admissions manager.

Bilateral Procedures - e.g. right and left hip replacements. A RFA will only be accepted for one procedure unless the bilateral procedure is occurring in the same admission (bilateral cataracts excluded). This is to ensure that the patient has been reviewed and assessed as clinically ready to undergo the subsequent procedure.

Multiple bookings - can be accepted if the treatments/procedures are independent of each other e.g. cataract extraction and joint replacement. The referring doctor must specify which procedures are prioritised. This may be indicated by the clinical priority urgency category assigned to both bookings e.g. if one is category 2 (within 90 days) and the other is category 3 (within 365 days) then the category 2 takes precedence. However if both RFAs have the same clinical priority urgency category the referring doctor should identify on the RFA which procedure is to be prioritised.

The patient should remain Ready for Surgery (RFS) for both procedures until a surgery date is assigned to the first procedure, at which time the second procedure is made Not Ready for Surgery (NRFS). Advice should be received from the doctor or patient when they can become RFS for the second procedure.

The only exception to the above is for ongoing regular treatment e.g. tissue expansion or change of supra pubic catheters.




If the procedures are dependent on each other (such is the case for patients having multimodality treatments), the patient can be listed for both procedures but listed as RFS for the surgery that needs to be completed first and NRFS for the subsequent procedure until the patient is cleared following the first procedure.

Duplicate bookings - a RFA will not be accepted for the same procedure with different referring doctors at the same hospital; or for the same procedure at a different hospital. The patient is to be advised of the situation and asked to make a decision as to the preferred waiting list they wish to remain on.

Contracts with Private Hospitals – Where a contract exists with a private hospital to undertake elective surgery/procedures for ACT Health, the following actions should be undertaken:

Patient should be added to the public hospital waiting list A copy of the RFA Form is to be held at the public hospital The patient should be managed as per this policy The private hospital should advise the public hospital when the procedure is

undertaken and patient is to be removed from the public hospital waiting list

3 MANAGING PATIENTS ON THE WAITING LIST

3.1 Calculating Waiting Times

The Listing Date is the date of acceptance of the RFA. Calculation of waiting time starts from this date.

Calculation of a patient’s waiting time includes only the time a patient is Ready for Surgery (RFS). Waiting time thus reflects a genuine waiting period.

Periods when patients are Not Ready for Surgery (NRFS) should be excluded in determining waiting time.

3.2 ‘Treat in turn’

The principle of ‘Treat in turn’ is one that can be applied to assist in the management of elective surgery and waiting times.

The basis of this principle is that patients are treated in accordance with their urgency category but that within each urgency category, most patients are treated in the same order as they are added to the waiting list.

The aim is to treat a minimum of 60% of people in turn, within a range of 60% to about 80% (rather than 100%), because differing patient requirements (as judged by the treating surgeon) and other aspects (such as efficient use of operating theatre time and training of surgical trainees) also should be taken into consideration.

Treatment in turn assists in standardising urgency categorisation as it provides greater predictability for the time patients wait. This should assist in ensuring that patients appropriately




categorised as category 2 are not assigned to category 1, ensuring they are treated within 90 days.

As such, thresholds have been established to prevent elective cases in category 2 and 3 being booked prematurely unless clinically indicated and/or in exception circumstances. The thresholds stipulate that category 2 patients should not be allocated a booked date for surgery earlier than 31 days after listing on the ESWL and no later than 90 days. Category 3 patients should not be allocated a booked date for surgery earlier than 91 days after addition to the ESWL and no later than 365 days.

The ‘treat in turn’ principle and compliance with booking thresholds will be monitored and breaches reported on a quarterly basis and tabled at the Surgical Services Taskforce for discussion and any subsequent actions.

3.3 Clinical Review

Clinical Review is defined as a review of a patient on the waiting list to ensure that their waiting time remains appropriate for their clinical condition

Following a clinical examination, the patient may be reassigned a different priority rating from the initial category based on the clinical assessment

GPs can initiate a patient review, as some conditions will change while the patient is waiting for treatment. The patients should remain in their current clinical priority category while undergoing clinical review (they should not be moved into NRFS)

Following the clinical review, a new RFA is not required unless the original procedure being undertaken has changed

The major objectives of a clinical review are to determine:

Change in the clinical condition of the patient Any required changes in the patient’s clinical urgency priority for the procedure Is admission still required?

The clinical review can be facilitated by the Specialty Liaison Nurse or equivalent and conducted by an appropriate clinician:

Treating doctor or delegate General Practitioner (GP) Specialist Consultant or delegate e.g. registrar




3.4 Ready for Surgery (RFS)

A RFS patient is defined as a patient who is prepared to be admitted to hospital or to begin the process leading directly to admission for surgery. Patients should only be added to a waiting list (that is, regarded as ready for surgery for the purpose of monitoring waiting times, and for the purpose of allocation of a surgery date), when the patient is personally and clinically ready for surgery. This means that they should only be regarded as ‘in the queue’ when they are ready for surgery and waiting times should only be measured for the time the patient is ready for surgery.

Patients deferred for personal reasons should not be added to a waiting list until they are ready for surgery. The patient should be suspended from the waiting list if they defer after being initially ready for surgery.

3.4.1 Delayed Patients

A patient remains classified as RFS if their admission is postponed/delayed due to reasons other than the patient’s own availability, e.g. unavailability of doctor, operating theatre or bed.

3.4.2 Declined Patients

The hospital must record the reason for patients declining a planned admission date on the electronic waiting list and on the patient’s RFA.

3.5 Not Ready for Surgery (NRFS)

A Not Ready for Surgery patient can be defined as a patient who is not available to be admitted to hospital until a future date, and is either:

Staged1. Pending improvement of clinical condition - Patients for whom surgery is indicated, but

not until their clinical condition is improved, for example, as a result of a clinical intervention OR

Deferred2. Patients who for personal reasons are not yet prepared to be admitted to hospital.

3.5.1 Not Ready for Surgery – Staged Patients

Staged patients have undergone surgery or some other treatment and are waiting for follow-up surgery that needs to occur at a particular, known time in the future – usually within a time period measured in days or weeks, rather than months or years.




The follow-up surgery can be:

Part of a ‘package’ of surgery, for example, removal of the fixation device after an initial surgical episode for the internal fixation of a fracture

Checking a patient’s status after an initial surgical episode, for example, a check cystoscopy after initial urological cancer surgery

A surgical episode after non-surgical care, for example, rectal cancer surgery 6-8 weeks after neoadjuvant chemo radiotherapy for colorectal cancer

A surgical episode for a paediatric patient, indicated at a future developmental stage

Once the identified NRFS staged timeframe is completed the patient then returns to the RFS category as indicated by the treating doctor.

Staged patients should be designated as ready for surgery at the beginning of the window of time during which their procedure is indicated. They should be allocated to the urgency category that is appropriate to the timeframe.

For example:

For the rectal cancer surgery example above, the patient should be added to the waiting list as urgency category 1 and made NRFS for 6 weeks after their neoadjuvant chemo radiotherapy. The patient should then be made RFS. Their waiting time would be measured from the time they are ready for surgery, that is, from the point in time 6 weeks after their chemo radiotherapy

If a patient needs a check cystoscopy between 12 and 15 months after their initial urological cancer surgery, they should be staged for the 12 month period after the initial surgery, and then have their status changed to ready for surgery, in the urgency category. Their waiting time would be measured from the time their status changes to ready for surgery that is 12 months after their original surgery

3.5.2 Not ready for surgery – Pending Improvement of Clinical Condition

Category one patients who are identified as not ready for surgery (NRFS) because of a medical condition that requires treatment or management, must have a PAC appointment arranged within 48hrs of being made NRFS and have a scheduled appointment within 5 working days

Patients who are waiting for an implant can be made NRFS until a TCI is assigned e.g. EVAR

Category two and three patients can only be made NRFS following a Clinical PAC assessment which clearly identifies the patient as NRFS pending improvement of




clinical condition. This decision must be documented in the patient’s electronic record when the patient’s status is changed to NRFS

A patient cannot be deemed NRFS where a documented TCI is allocated excepting patients who have had their surgery postponed and surgery is being planned for a specific date in the future

3.5.3 Not Ready for Surgery – Deferred for Personal Reasons

These are patients who are not ready for surgery for personal (non-clinical) reasons, such as work commitments. Deferred patients should not be added to a waiting list until their personal circumstances mean they are ready for surgery, and their urgency category should be assigned at that time. Once placed on the list, any time subsequently spent deferred should be subtracted from the amount of time recorded as waiting.

The maximum cumulative timeframes for patients deferring surgery is:

Cat 1 - 15 days (however, patient deferring their treatment in this category should be discussed with the referring doctor)

Cat 2 - 45 days Cat 3 -180 days

A decision to remove the patient from the waiting list may be made if a patient defers more than two offers or exceeds the maximum number of Not Ready for Surgery days.

If a patient fails to attend a pre-admission clinic appointment then their risk for surgery remains undetermined. In this case their status on the waiting list should be discussed with their treating doctor.

Suspension Review Date is defined as the date when it is estimated or recorded on the RFA that a deferred or staged patient will become ready for admission, i.e. RFS.

A Suspension Review Date must be set each time a patient:

Is added to the waiting list as a staged admission (NRFS) or defers admission whilst on the waiting list

Status changes from RFS to NRFS Status remains NRFS following a clinical assessment

A Managing NRFS Patient Report, listing details of each patient whose suspension review date will become due in the following month, must be generated at least monthly. Following an assessment, patients will either:

Be assigned another review date




Be returned to Ready for Surgery within the appropriate clinical priority category Have a planned admission date scheduled Be removed from the waiting list

3.6 Admission Process

Effective admission and discharge processes are required to ensure optimal use of operating theatre time and hospital beds.

Equity and Priority of Access for Admission - the following criteria must be considered when selecting patients from the waiting list for admission:

Clinical priority urgency category The length of time the patient has waited in comparison with similar category

patients Previous delays Pre-admission assessment issues/factors

e.g. elderly people living alone or those having to travel long distances Resource availability

e.g. theatre time, staffing, equipment and hospital capacity

Relevant consultation with staff from:

Treating Doctor Theatres Admissions Pre-admission Liaison nurses Other Departments if relevant e.g. Medicine, Radiology Community Care and Post discharge services for an effective communication to

handover patient care to their General Practitioner or other relevant community services as required

Aboriginal Liaison Officer (ALO) if available, so the patient/carer is asked if they would like to request an ALO to contact them either before their admission or a visit during their admission

Tentative Admission Date:

A Tentative ‘To Come In’ (TCI) Date is the date that it is proposed that a patient on the waiting list will be admitted for an episode of care. This date is to be entered on the electronic waiting list.




Once a tentative TCI date is confirmed the patient should be contacted by phone to determine acceptance of admission followed by a letter from the surgical bookings office.

Patients should be supplied with relevant information for their hospitalisation, including the proposed length of stay, discharge procedures and post operative care and follow up.

The below table indicates the recommended timeframes for allocation of a TCI date:

Clinical Priority Category Recommended allocation of TCI

No patient in Category 1 should wait longer than 30 days TCI on listing or within 5 days

No patient in Category 2 should wait longer than 90 days TCI within 45 days

No patient in Category 3 should wait longer than 365 days TCI within 270 days

Short Notice Patients:

Patients may agree to be available at “short notice” to have their surgery performed. This is to be indicated in the electronic waiting list general comments section. For example if there is a cancellation, the Surgical Booking Clerks should maintain a list of patients who are available to have their procedure/treatment performed at short notice. Patients should be asked to indicate a preparedness to accept short notice of admission. The hospital should determine what period of time prior to admission is regarded as short notice and for which procedures short notice is appropriate.

Preadmission Assessment:

Patients must be clinically assessed before admission to the hospital to confirm suitability to undergo the intended procedure/treatment, associated anaesthetic and necessary discharge plans. Patients will be assessed by the relevant clinicians including registrars, nurses and allied health professionals in a public hospital clinic or by a telephone interview.

3.7 Hospital Initiated Postponement (HIP)

Hospital initiated postponements must be minimised. Decisions to postpone a patient’s surgery must involve relevant medical and peri-operative staff, the Surgical Booking Clerk and senior hospital management.

Patients who are postponed by the hospital, doctor or for clinical reasons, remain “Ready for Surgery” “delayed” and the following actions taken:

Inform the patient of the postponement with the maximum amount of notice




Category 1 patients and patients postponed on the day of procedure/treatment must be notified by a senior member of the surgical/medical team. Appropriate peri-operative management staff can notify all other patients, although it is preferable for the treating doctor or delegate to speak with the patient

Postponed patients must have priority over others not previously postponed Postponed patients are to be placed on the next available procedure/treatment list,

appropriate to the patient’s clinical priority If a patient has been postponed twice and cannot be treated within the appropriate

clinical priority timeframes, the hospital must actively investigate options for the procedure/treatment to be undertaken at another public hospital.

Offer the following support options to the patient, where relevant:

Contact a family member or friend Arrange and pay for transport home, accommodation, food, etc. Counselling services Access to a complaints service Organise the rescheduled date for procedure/treatment and notify

the patient of the new admission date on the day of postponement or within 5 working days, if possible

Provide information about what they should do if their condition deteriorates

The opportunity to discuss with a doctor, medical issues that might arise as a result of the postponement

The name and contact details of the Surgical Booking Office, should they require further information

3.8 Patient Initiated Postponement:

When a patient postpones an agreed date for procedure/treatment for personal or social reasons, a patient initiated postponement should be:

Recorded on the electronic waiting list and RFA Reviewed to determine if: A new date is to be scheduled The patient is to be categorised as “Not Ready for Surgery” “deferred”, or Removed

from the waiting list. Patients are only permitted to postpone maximum of two (2) times for personal or

social reasons, unless there are extenuating circumstances.




If a patient arrives for treatment/procedure and decides to cancel after admission, the following steps should be taken:

The surgeon should be advised The patient should be admitted and discharged The reason for cancellation should be recorded and an appropriate clinician should

discuss the requirement for surgery with the patient’s General Practitioner If the surgery is still clinically required and the patient agrees, the patient should be

re-booked on day of discharge with original listing date Or removed from the waiting list

3.9 Reporting of Hospital Initiated Postponements (HIPs)

To ensure consistency of reporting of HIPs the following method is to be used:-

Elective theatre dates are booked 2- 4 weeks in advance Patients are phoned to confirm their availability, and a ‘To Come in’ date (TCI) is

entered into ACTPAS A letter is sent to the patient confirming the date and details of admission HIPs are reported on all patients that have been notified of a surgery date The Waiting List Entry in ACTPAS is checked for each patient to confirm patient

notification has occurred

4 DEMAND MANAGEMENT

A quarterly review of the waiting lists will be undertaken in order to identify clinical specialties experiencing a high demand of patients exceeding their clinical priority time frames and a report generated. Clinicians will be sent a copy of this report, for their response in writing within 14 days outlining an action plan to manage their long wait patients. All reports and responses will be forwarded to the Director of Territory Wide Surgical Services for information and discussion with the Heads of Surgery at hospital sites. Initial strategies to manage the demand should include:

Clinical Review

Transfer of Patients to Doctors with a shorter waiting time Transfer of Patients to another facility Increase theatre utilisation as approved by Executive Director Surgery and Oral

Health (e.g. extra sessions). Use of short notice or adhoc lists




4.1 Demand Management Escalation

If it is established that the treating specialist is unable or unlikely to be able to provide treatment in the recommended timeframe and where initial management strategies have been implemented and not reduced the demand, patients will be referred to another clinician and service in order for their treatment to be completed. Any outsourcing of public elective surgery work will be assessed according to the specific outlined requirements and best value for money.

4.2 Transferring Patients to another Facility for surgery

A patient may be listed at one hospital and subsequently requires transfer to a different hospital for a procedure within the ACT and Southern NSW Local Health District (SNSWLHD).

The majority of patients requiring transfer to another hospital will be for a clinical reason and to ensure the surgery occurs in the safest and most appropriate setting. In this case the requesting hospital provides informs TWSS of this request as soon as possible with a clinical rationale.

TWSS to contact the Manager of Surgical Bookings at the receiving hospital to advise of transfer.

TWSS to send Request for Admission form to receiving facility and notify patient and surgeon of transfer.

If a patient is already listed for a surgical procedure, which is clinically appropriate at a hospital, equipment unavailability cannot be deemed as the reason for transfer. In this instance the hospital should make every attempt to loan the equipment for the procedure to be undertaken. Discussion should occur between Theatre Managers at both facilities. If a compromise is unable to be reached on the most appropriate facility to undertake the procedure the issue will be referred to the Territory-wide Surgery Management Committee.

The following steps must be followed when a transfer occurs across facilities to ensure the data is reported as per the NHDD requirements:-

The booking at the hospital where the patient will be treated is entered onto the waiting list with the same listing date and history as the booking at the original hospital, and with the current clinical priority category when the RFA is received from the initiating hospital

The booking at the original hospital should be removed only when confirmation of the patient’s booking is received at the receiving hospital and documented using the following reason codes:

Removal reason code for interhospital transfer – Transferred to another hospital’s waiting list

Removal reason code for contracted patient – ‘contracted patient – private hospital’ OR ‘contracted patient – public hospital’

If a contracted patient, a copy should be sent to the receiving hospital and the original retained for auditing at the original hospital.




When a patient is booked at one hospital and subsequently has the procedure carried out at a different hospital within the ACT and Southern NSW Local Health District (SNSWLHD), the following steps must be followed:

The booking at the hospital where the patient will be treated is entered onto the waiting list with the same listing date and history as the booking at the original hospital, and with the current clinical priority category when the RFA is received from the initiating hospital

The booking at the original hospital should be removed only when confirmation of the patient’s booking is received at the receiving hospital and documented using the following reason codes:

Removal reason code for interhospital transfer – Transferred to another hospital’s waiting list

Removal reason code for contracted patient – ‘contracted patient – private hospital’ OR ‘contracted patient – public hospital’

If a contracted patient, a copy should be sent to the receiving hospital and the original retained for auditing at the original hospital.

4.3 Removing Patients from the Waiting List

In addition to removal from the waiting list once the planned procedure is performed, patients may need to be removed from the waiting list for other reasons

Hospitals should exercise discretion on a case by case basis to avoid disadvantaging patients in the case of genuine hardship, misunderstanding and other unavoidable circumstances.

Reason Category 1, 2 & 3 Actions

Patient declines treatmentorrequests removal for other reasons.

Forward a copy of the RFA with a covering letter (Appendix 3) to the patient’s treating doctor informing them of the removal of the patient from the waiting list unless the treating doctor advises otherwise within 5 working days




Obtain authority for Category 1 (30 day) patients prior to removal from the waiting list

Once decision is made to remove a patient from waiting list: Remove the patient from the waiting list Advise the GP that the patient has been removed

(Standard Letter Appendix 3) Advise the patient of the removal on the waiting

list (Standard Letter Appendix 3) Document all actions in the electronic record

Patient refuses treatmenton 2 occasions (including other genuine offers of another doctor/hospital) or in deferring exceeds the total cumulative maximum number of NRFS days:Cat 1 > 15 daysCat 2 > 45 daysCat 3 > 180 daysPatient fails to arrive for treatment on >1 occasion without giving prior notice and with no extenuating circumstances.Patient not contactableon 2 occasions(one by phone, one by letter)

Attempt to obtain the patient’s correct contact details via all the outlined methods below:

Referring doctor, GP, medical records, next of kin & telephone directory search

Remove the patient from the waiting list Advise referring doctor and GP that patient has

been removed (Standard Letter Appendix 3) Document actions on the RFA and the electronic

record

Patient deceased Obtain verification (usually verbally from the patient’s relative, general practitioner or specialist)

Remove patient from the waiting list Document all actions on the RFA and the electronic

record

Note: If a patient was initially removed from the waiting list due to reasons other than admission and in the following month the waiting list record needed to be re-activated for the same procedure, then the patient should be re-booked with the original listing date and history (clinical priority category and delays etc.).




5 RECORD KEEPING

Hospitals must keep accurate records of waiting list information.

5.1 Postponement of Planned Admission

Accurate records are to be maintained in the patient’s electronic record for patients postponing their elective surgery and the reason for postponement documented

A patient’s postponement history should be readily available to staff making decisions about postponing future patients

5.2 Removal of Patients from the Waiting List (other than admission)

All patients who have been removed from the waiting list (other than admission) require documentation in the patient’s electronic record detailing the reason for removal and the date of removal

Treating doctors and GPs will be advised by mail (Appendix 3)

Removal Reason Information to be Recorded/Filed (RFA & Electronic)

Patient Deceased Record the name of the person who has notified the hospital that the patient is deceased

Non contactable Evidence of contact: patient letters returned (return to sender) documentation of attempts to contact through

referring Doctor, GP, medical records, next of kin & telephone

directory search

Decline treatment or clinical review/not required

Documentation that the patient advised to contact the referring doctor

Obtain authority for Category 1 (30 day) patients prior to removal from waiting list

Fail to Arrive for Treatment

Documentation that: patient has failed to arrive for treatment on the

planned admission date on > 1 occasion without prior notice and without good reason

advise the patient to be clinically reassessed by the treating doctor




6 AUDITING THE WAITING LIST

6.1 Clerical Audit

The Central Wait List Office is responsible for conducting and monitoring the clerical audit program across the hospitals, maintaining clerical audit standards and addressing issues arising from the audits

All patients on the waiting list should be contacted if they have been waiting for six months or longer from listing date, to ascertain if they still require admission. Two contacts should be attempted, one by letter (Appendix 2) and one by telephone

On completion of clerical audits, a summary report must be sent to the Manager – Territory Wide Surgical Services for tabling at the Surgical Services Taskforce

Documentation of the patient audit must be made in the patient’s electronic record, including responses received and the action taken

6.2 Request for Admission (RFA) Audit

The surgical bookings office is responsible for a review of the waiting list and must be undertaken six monthly to ensure that accurate information is provided to clinicians and administrators on request.

The Surgical Booking Clerk will assess the RFA for accuracy by cross checking patients listed on ACTPAS under each surgeon, against RFAs held in a folder, utilising the following minimum data set.

1. Patient details:

Full name Date of birth Patient identity number (pid) Gender Address Phone number Accommodation status

2. Clinical details:

Diagnosis Proposed procedure Clinical priority category




The Surgical Booking Clerk will document all necessary amendments or updates in the patient record, to provide a clear audit trail.

After each individual patient is audited, a comment must be placed in the comments section of patient’s waiting list entry in ACTPAS stating: ‘RFA AUDITED - DETAILS CORRECT’ or ‘RFA AUDITED – (e.g.) NOK added, telephone number amended, operation description corrected’

7 DOCTOR’S LEAVE – TEMPORARY OR PERMANENT

Includes Annual, Study, Conference and Unplanned sick or bereavement leave To ensure appropriate theatre scheduling, doctors are required to provide a

minimum of 28 days notice of intended leave. Leave includes annual, study and conference

The hospital will ensure appropriate communication of scheduled reduced activity periods, promulgated public holidays and recognised holiday periods. The hospital will develop and implement plans, in consultation with appropriate clinicians and services, regarding these periods

A patient’s clinical priority category and listing date does not change as a result of doctor’s leave

Patients whose clinical priority cannot be met during a period of leave may not be booked on that surgeon’s waiting list. A management plan for affected patients should be developed and implemented for all leave

Affected patients are those who during the leave period:

Already had a planned admission date Will exceed their clinical priority timeframe during the leave period.

A patient’s management plan should ensure affected patients: Are assured that their queue order will not be affected Know who the replacement doctor will be Are advised if clinical review is required Are provided with information regarding their expected waiting time A management plan for affected patients should be developed and implemented for

all leave in consultation with the referring surgeon, Specialty Liaison Nurse (TCH), Head of Unit, Clinical Director of Surgery (TCH) / Director of Peri operative Services (CHC), and Surgical Bookings Clerk




7.1 Resignation, Retirement or Sudden Death

Following notification of planned and unplanned resignation or retirement, sudden death or failure to be reappointed, or notification of intention not to renew a contract no further patients will be added to the doctor’s waiting list. A management plan for affected patients already listed requires:

Consultation with Head of Unit, Clinical Director of Surgical Services (TCH) / Director of Medical Services (CHC), Peri operative Suite Management, Surgical Bookings Manager and relevant Booking Clerk

Location of a replacement treating doctor in consultation with Head of Unit, Clinical Director of Surgical Services (TCH) / Director of Medical Services (CHC)

Clinical review (within 3 months) is required for patients remaining on departing doctor’s waiting list

All patients will be clinically and/or administratively reviewed and a plan developed by the Head of Unit




8 DEFINITIONS

Definition Explanation

Acceptance date Acceptance of the RFA will be deemed when the following are complete: The minimum RFA data set is completed The RFA form is signed and dated on page 4 It is not an excluded procedure

Addition to the waiting list

As soon as a decision is made that a patient is in need of admission to the hospital and the admission is not required within 24 hours, the treating doctor should complete a RFA form and forward it to the hospital within 5 working days. The patient will be added to the electronic waiting list within 3 working days of acceptance of a complete, accurate and legible RFA form. The date the RFA is accepted becomes the patient’s listing date. This date is used in the calculation of the waiting time.

Admission The Australian Institute of Health and Welfare (AIHW) defines admission as the process whereby the hospital accepts responsibility for the patient’s care and/or treatment. Admission follows a clinical decision based upon specific criteria that a patient requires same day or overnight care and treatment.

There are two types of Admission:

Emergency Admission is defined as surgery to treat trauma or acute illness subsequent to an emergency presentation. The patient may require immediate surgery or present for surgery at a later time following this unplanned presentation. This includes where the patient leaves hospital and returns for a subsequent admission. Emergency surgery also includes unplanned surgery for admitted patients and unplanned surgery for patients already waiting for an elective surgery procedure (for example, in cases of acute deterioration of an existing condition.

Elective Surgery is defined as planned surgery that can be booked in advance as a result of a specialist clinical assessment resulting in placement on an elective surgery waiting list

Admission Date Date on which an admitted patient commences an episode of care

Admitted patient A patient who undergoes a hospital’s admission process to receive treatment and/or care





Anticipated election status

Recorded when the patient is added to the waiting list, it is the anticipated financial election the patient will make when admitted for the planned procedure/treatment.

Classifications are: Medicare Shared - Public patient Medicare Eligible - Private patient Medicare Eligible - Department of Veterans Affairs patient Medicare Eligible - Other (compensable, Defence forces etc) Medicare Ineligible – (e.g. Overseas visitor)

Clerical Audit A clerical audit is a regular and routine clerical check that the information the hospital has of patients waiting for admission is correct. It will facilitate the identification of patients who no longer require admission or who have duplicate bookings

Clinical Priority Urgency Categories

A clinical priority urgency category is allocated to a patient based on the referring doctor’s assessment and nationally agreed guidelines for surgery of the priority with which a patient requires elective admission. Clinical priority categories are:

Category 1 Procedures that are clinically indicated within 30 days



Not Ready for Surgery – staged (Clinical reasons)Not Ready for Surgery – deferred (Personal reasons)

Clinical Review Review of a patient on the waiting list to ensure that their waiting time is appropriate for their clinical condition.

Day of surgery admission

(DOSA)

Day of surgery admission - patients are admitted into hospital on the day of their procedure and remain in hospital for at least one post-operative night.

Day Only Surgery (DO) Day Only Surgery involves the patient being admitted and discharged on the day of surgery.

Also referred to as Day Surgery.

Declined Patient A patient who declines a planned admission date for treatment.

Deferred See Not Ready for Surgery “deferred”





Delay See postponement

Demand Management Processes and Strategies initiated to manage the number of patients exceeding their clinical priority urgency timeframes waiting on the Wait List for elective surgery

Discharge Intention Recorded when the person is added to the waiting list. It identifies whether the referring doctor expects that the person will be admitted and discharged on the same day (i.e. day patient) or will stay at least overnight.

DOSA DOSA is an acronym for day of surgery admission.

EDSU EDSU units are specifically designed to accommodate patients - elective and emergency, who meet specific admission criteria including:

Absolute expectation of discharge within 24 hours, preadmission screening (elective patients), agreed clinical guidelines in place and agreement to protocol based nurse initiated discharge.

Electronic waiting list Patient administration/ management system used by the hospital to manage the waiting list e.g. ACTPAS.

Exceeding Clinical Priority Timeframes or Overdue

Patients are considered overdue if they have waited in excess of the time recommended for the assigned ready for surgery clinical priority category.

Indicator procedure

Code

The procedure or treatment the patient is to undergo when admitted.

Inpatient Patients who are formally admitted to a hospital or health service facility. Formally admitted patients can be Day Only or overnight.

Listing Date Listing Date is the date of Acceptance of the RFA Form. Calculation of waiting time starts from this date.

Listing Status Indicates the status of the person on the waiting list that is the extent to which a patient is ready and available for admission. This may change while the patient is on the waiting list e.g. after a clinical review.

The patient may be:

Ready for Surgery (Category 1, 2 or 3) Not Ready for Surgery (Staged or Deferred)





Long-wait patients Surgical patients who are Ready for Surgery and have waited longer than their recommended clinical category timeframe are termed long-wait patients.

Medicare eligibility Patients must be identified as being eligible or not eligible for treatment under the Medicare agreement for each episode, and a record of the patient’s Medicare number is to be made at the time of listing - see Anticipated Election Status.

Not Ready for Surgery

(NRFS)

A Not Ready for Surgery patient can be defined as a patient who is not available to be admitted to hospital until a future date and is either:

Staged – (Planned or Clinically unfit) Deferred (not ready for personal reasons)See Clinical Review Section 5.3 for timeframe for NRFS patients.

A postponement of admission by the hospital does not render the patient Not Ready for Surgery. These patients should remain on the waiting list as they are still genuinely waiting, but are delayed.

Not Ready for Surgery - “deferred” for personal reasons

A deferred patient is a patient who for personal reasons are not yet prepared to be admitted to hospital. Examples include patients with work or other commitments that preclude their being admitted to hospital for a time.

It is mandatory to indicate a reason for deferring.

The reason a patient is deferred may be reported as follows:

A patient is going on holidays and will be unavailable for admission A patient is unable to obtain home support A patient is unable to accept a date due to work commitments A patient is unable to accept a date for other significant reasons e.g.

personal carerPatients may not be added to the waiting list as Not Ready for Surgery deferred.

Not Ready for Surgery - “staged” patients

Patients who have undergone a procedure or treatment and are waiting for follow-up elective surgery, where the patient is not in a position to be admitted to hospital or to begin the process leading directly to admission for surgery, because the patient’s clinical condition means that the surgery is not indicated until some future, planned period of time.

Examples include a patient who has had internal fixation of a fracture who will require removal of the fixation device after 3 months, a





patient who requires a ‘check’ cystoscopy to check for cancer 12 months after surgery to remove a tumour in the bladder, and a patient requiring rectal cancer surgery 6-8 weeks after neoadjuvant chemo radiotherapy for colorectal cancer

It is mandatory to indicate a reason for stagingThe reason a patient is staged may be reported as follows: Pending Improvement of clinical condition Patients for whom surgery is indicated, but not until their clinical

condition is improved, for example, as a result of a clinical intervention. Examples include patients who require a cardiac work-up before a total hip replacement and patients with respiratory insufficiency that requires physiotherapy to maximise respiratory function before a hernia repair. For such patients, a decision has already been made that surgery should take place. Patients should not be regarded as ‘not ready for surgery – pending improvement of their clinical condition’ when they are undergoing monitoring or investigations before a decision is made as to whether surgery is requiredPlanned

A patient requiring treatment as part of periodic treatment A patient requiring treatment as part of a staged procedure

(includes obstetric patients) A planned re-admission for a patient with a predictable morbid

process, requiring periodic treatment of the ongoing disease process A planned re-admission for review of status following previous

treatment

To Come In Date (TCI) The date on which it is proposed that a patient on the waiting list will be admitted for an episode of care.

Planned length of stay The number of nights the patient is expected to stay in hospital as an inpatient. This information will be used for discharge planning and bed management.

Planned procedure The planned procedure is the procedure or treatment the patient is to undergo when admitted.





Postponement A patient’s elective admission may be postponed by the hospital due to high emergency admissions or other hospital related reasons.See Ready for Surgery “delayed”

A patient may also postpone for personal reasons.See Not Ready for Surgery “deferred”

Pre-admission Patients are assessed before admission to the hospital for their suitability to undergo the intended procedure/treatment, associated anaesthetic and discharge plans.

Presenting Problem The problem or concern that is the reason for seeking health care or assistance (NHDD).

Private/Chargeable patients (including DVA & WC etc)

Persons admitted to a public hospital who elect to choose their treating doctor(s) will be charged for medical services and accommodation.

Public Patient A Medicare eligible patient admitted to a public hospital who has agreed to be treated by a nominated doctor of the hospital’s choice and to accept shared ward accommodation. This means the patient is not charged.

Ready for Surgery (RFS)

A Ready for Surgery is defined as patients who are prepared to be admitted to hospital or to begin the process leading directly to admission for surgery.

The process leading to surgery could include investigations/procedures done on an outpatient basis, such as autologous blood collection, pre-operative diagnostic imaging or blood tests.

Ready for Surgery - “Delayed”

A patient is regarded as Ready for Surgery but delayed where the hospital decides to postpone admission and reschedule a person’s planned admission date because of:

Non-availability of operating theatre (staff, equipment, resources etc.) Non-availability of bed Non-availability of bed; pressure of emergency admissions Non-availability of doctor

It is mandatory to indicate the reason for the patient’s admission being delayed.





Removing patients from the waiting list, other than for admission

Patients can be removed from the waiting list for reasons other than for admission:

Patient declines treatment or requests removal Patient defers treatment on 2 occasions Patient defers & exceeds the total cumulative maximum number of

Not Ready for surgery daysCat 1 > 15 days; Cat 2 > 45 days; Cat 3 > 180 days

Patient fails to arrive on 1 occasion, with no notice or extenuating circumstances

Patient not contactable Patient deceased

Request for Admission form (RFA)

Requests for admission to hospital need to be on an approved form and contain a minimum data set as specified in this framework

Referring Doctor Doctor who is referring the patient to the waiting list

Same Day Surgery See Day Only Surgery (DO)

Specialty Specialist’s area of clinical expertise. Where a specialist undertakes surgical procedures that can be classified into different specialities then the specialist will have a different list for each specialty (e.g. Obstetrics/Gynaecology).The broad categories required for reporting are: Cardiothoracic ENT General Surgery Gynaecology Neurosurgery Ophthalmology Orthopaedic Plastic Urology Vascular

Staged See Not Ready for Surgery “staged”





Short Notice/ Standby Patient

Patients may agree to be available on the “short notice” list to have their surgery performed if there is a cancelled procedure. The hospital should determine what period of time prior to admission is regarded as short notice and for which procedures are appropriate.

Status Review Date (SRD)

This is the date determined for an assessment (clinical or administrative) of a deferred or staged person (i.e. Not Ready for Surgery) to determine if the patient has become ready for admission to the hospital at the first available opportunity (i.e. Ready for Surgery).

Treating doctor The medical officer/senior clinician (a visiting practitioner, staff specialist or academic clinician) responsible for the care of the patient, and under whose care the patient is to be admitted.

Waiting List A waiting list is kept by the hospital. This contains the names and details of patients registered as requiring elective admission to that hospital. Admission may be for same day (admission and discharge on the same day) or other acute inpatient services requiring overnight or longer stay. These patients may or may not have a planned admission date and may be proposing to be public or private patients.

Waiting Time Time a patient spends as Ready for Surgery.




9 APPENDICES

Appendix 1 - Patient Notification Letter<Patient Name><Address Line 1><Address Line 2>

Dear <Patient Name>

I am writing to confirm that as of <INSERT DATE> you have been placed on the elective surgery waiting list for a <INSERT PROCEDURE> under the care of <INSERT SURGEON> at <INSERT HOSPITAL>.

Your surgeon has determined your clinical priority category to ensure you have your surgery completed in the recommended timeframe. Every attempt will be made for you to have your procedure under the care of the referring surgeon and to provide your surgery within the clinically recommended timeframe; however this may involve referring you to another doctor or hospital in the ACT.Once a planned admission date has been allocated for your procedure, you will be notified of the date and provided with further information to help you prepare for your hospital stay.

Sometimes it is necessary to delay booked surgery to make way for life-threatening cases, which are admitted through the hospital’s emergency department. These emergency cases will always receive priority over elective surgery. However, the hospital will make every effort to avoid such postponements and to reschedule delayed patients as soon as practicable.

Should your clinical condition change, you should notify your general practitioner. Changes in your condition or general health may have implications for the timing of your procedure or lead to your clinical priority category being re-assessed.

Due to the high demand on the elective surgery waiting list we aim to book the surgery lists as efficiently as possible. One way you can help us in reducing delays is to ensure you provide us with any updated information. Therefore:

As a patient on the waiting list, you have a responsibility to inform the hospital: If you decide not to proceed with the procedure for any reason. For example, if the procedure has

been conducted at another hospital or you have decided to seek treatment privately or to opt for an alternative treatment

Of any changes to your contact details If you are going to be unavailable for any extended period

The hospital may remove you from the waiting list in consultation with your specialist if: The hospital is unable to contact you because you have not informed them of a change in your

contact details You fail to present for the procedure without providing the hospital with prior notice You postpone your surgery on two occasions for personal or social reasons

The attached brochure ACT Elective Surgery Access provides additional information about the elective surgery waiting list. Please take the time to read this brochure.

Should you have any questions, please do not hesitate to contact us on the number below.

Yours sincerelyCentral Wait List Team Territory Wide Surgical ServicesACT HealthTel: (02) 6205 1122




Appendix 2 – Audit letter

Dear <patient name>

We are continually updating our elective surgery waiting lists so they remain accurate, complete and ensure your timely access to our services.

To help us maintain an accurate waiting list we ask that you complete the attached form and return it in the envelope provided within 10 working days.

We acknowledge that you may have previously received and replied to this request; however it is important that this information is obtained regularly, so we can review and update our records. We apologise for any inconvenience.

Should your clinical condition change, you should notify your general practitioner or your specialist. Changes in your condition or general health may have implications for the timing of your procedure or lead to your clinical priority category being re-assessed.

If you do not confirm you wish to remain on the list within 10 working days of receiving this letter, you may be removed from the waiting list and your surgeon and your general practitioner will be advised accordingly.

If you have any questions or require assistance in completing the attached form, please do not hesitate to contact the Surgical Bookings office on the number below.

Yours sincerely

Surgical Bookings Office\Hospital nameTel:

<DATE>




Appendix 2 – Audit letter

SECTION 1: YOUR PERSONAL DETAILSAre the details shown below correct?

Patient Details Local Doctor Details (GP)

Please insert details

Change of Patient Details:

Name Telephone (H)Address: Telephone (W)

Suburb Telephone (M)PostcodeState

SECTION 2: YOUR WAITING LIST SURGERY OPTIONSPlease place a tick in your selected option:

OPTION 1: I still require my surgery and I AM READY FOR SURGERY AT THIS TIME. YES

OPTION 2: I have already had my surgery – please remove me from the waiting list.

Please specify where you had your surgery & date: ______________________________________

OPTION 3: I no longer require the surgery – please remove me from the waiting list.

Reason: __________________________________________

Thank you for taking the time to complete this form. Please sign this form and return it in the reply paid envelope within 10 working days .

Signature _________________________

Date ______ / ______ /




Appendix 3 - Removal from Waiting List Letter

Dear <insert Dr’s name>

I am writing to advise you as of <insert date> your patient:

<insert patient name>

<insert patient address>

(Choose the appropriate option)

has been removed from the elective surgery waiting list at <insert hospital name>, as the patient

<select reason>- no longer requires treatmentseeking/treated elsewheretreated by another surgeonrefused 2 dates for surgerycould not be contactedpatient not available within timeframerequests removal deceased

If you have any concerns or require further information about the removal of your patient‘s name from the waiting list, please contact the Surgical Bookings Officer on < > between 9am to 4 pm Monday to Friday.

Yours sincerely

<Signature block>




Appendix 4 – Reclassification of Clinical Priority form

ACT Health

Re-classification of Clinical Priority Form

Complete details or affix labelURN:

Surname:

Given name:

DOB: Gender:

Date:

Patient:

Date of Clinical Review:

Original Clinical Priority Category:

New Clinical Priority Category:

Clinical reason for re-classification

Authorising Doctor(or Nominated Officer):

Print Name:

Signature:

Designation:




Appendix 5 – Notification to patient of Registration on the waiting list

Patient ID:

<PATIENT NAME>

<ADDRESS LINE 1>

<ADDRESS LINE 2>

Dear <INSERT NAME>

I am writing to confirm that your request for elective surgery has been received on <Date on Register> for a surgical procedure under the care of <Doctor>.

To assist in your preparation for surgery, you are required to complete the enclosed Patient Health Questionnaire (PHQ). Please return the questionnaire within 5 working days. You will not be placed on the Elective Surgery Waiting List until this form is returned.

Return the questionnaire in the reply paid envelope provided

or

email to: [email protected]

- Please note that some free email providers scan emails for targeted advertising. This is not a breach of your privacy, although the PHQ is sent back at your own risk.

Your health is our priority and our staff are available to assist. If you have any questions or require assistance in completing the Patient Health Questionnaire, please do not hesitate to contact the Central Wait List team on the number below.

Yours sincerely

Central Wait List TeamTerritory Wide Surgical ServicesACT HealthTel: (02) 6205 1122<Date>



mailto:[email protected]


Appendix 6 – Urgency Category outside National Guidelines

Patient ID: <DOCTOR NAME>

<ADDRESS LINE 1>

<ADDRESS LINE 2>

Dear Dr <INSERT NAME>

A Request for Admission (RFA) form for <INSERT PATIENT NAME> has been received by the central Wait List team on <INSERT DATE>.

It is noted that the clinical priority urgency category indicated on the RFA is not in line with the accepted National Elective Surgery Urgency Category Guidelines and no clinically verifiable justification for the change has been provided.

As stated in the Waiting Time and Elective Surgery Access Policy 2016, a clinically verifiable rationale must be documented on the RFA form if you have assigned the patient to a different clinical urgency category.

The RFA has been processed and the patient added to the Wait List under the clinical priority urgency category in line with the National Elective Surgery Urgency Category Guidelines. If this category is not correct, please complete the attached reclassification form with the required documentation and return to the central Wait List team in the enclosed reply paid envelope.

Thank you for your cooperation.

Yours sincerely

Central Wait List Team Territory Wide Surgical ServicesACT HealthTel: (02) 6205 1122

<DATE>




Appendix 7 – Letter to GP advising of patient who smokes

Patient ID: <DOCTOR NAME><ADDRESS LINE 1><ADDRESS LINE 2>


I am writing to advise you that your patient

<PATIENT NAME><ADDRESS LINE 1><ADDRESS LINE 2>

has been placed on the elective surgery waiting list for <OPERATION> under the care of <SURGEON>. This surgery will be performed at <HOSPITAL NAME>.

When your patient is booked for their procedure, they will be advised of the proposed admission date and given further information to prepare for surgery.

<PATIENT NAME> has stated in their patient health questionnaire that they are currently smoking and it is preferable that patients cease smoking 6 - 8 weeks before the admission date to help prevent complications.

A copy of the patient’s operation report and discharge summary will be sent to you following their surgery.

Yours sincerely


<DATE>




Appendix 8 – GP Notification Letter

Patient ID:

<DOCTOR NAME><ADDRESS LINE 1><ADDRESS LINE 2>


I am writing to advise you that your patient

<PATIENT NAME><ADDRESS LINE 1><ADDRESS LINE 2>

has been placed on the elective surgery waiting list for <OPERATION> under the care of <SURGEON>. This surgery will be performed at <HOSPITAL NAME>.

When your patient is booked for their procedure, they will be advised of the proposed admission date and given further information to prepare for surgery.

A copy of the patient’s operation report and discharge summary will be sent to you following their surgery.

Yours sincerely


<DATE>




Appendix 9 – Minimum Data Set Incomplete

Patient ID: <DOCTOR NAME><ADDRESS LINE 1><ADDRESS LINE 2>


Please find attached a Request for Admission (RFA) form for <INSERT PATIENT NAME> received by the central Wait List team on the <INSERT DATE>. This RFA has not been processed as the minimum requirements for accepting a RFA have not been completed.

As per the Waiting Time and Elective Surgery Access Policy 2016, RFAs will only be accepted if the minimum data set is complete.

Please complete the required information on the RFA as indicated below and return to the central Wait List team for processing.

Thank you for your cooperation.

Yours sincerely


<DATE>




Appendix 10 – Paediatric Notification Letter

Patient ID: Parent/Guardian of <PATIENT NAME><ADDRESS LINE 1><ADDRESS LINE 2>

Dear Parent/Guardian of <INSERT NAME>

I am writing to confirm that as of <INSERT DATE> your child has been placed on the elective surgery waiting list for a <INSERT PROCEDURE> under the care of <INSERT SURGEON> at <INSERT HOSPITAL>.

Your surgeon has determined your child’s clinical priority category to ensure their surgery is completed in the recommended timeframe. Every attempt will be made for your child to have their procedure under the care of the referring surgeon and to provide your surgery within the clinically recommended timeframe; however this may involve referring you to another doctor or hospital in the ACT.

Once a planned admission date has been allocated for your child’s procedure, you will be notified of the date and provided with further information to help you prepare for your child’s hospital stay.

Sometimes it is necessary to delay booked surgery to make way for life-threatening cases that are admitted through the hospital’s emergency department. These emergency cases will always receive priority over elective surgery. However, the hospital will make every effort to avoid such postponements and to reschedule delayed patients as soon as practicable.

Should your child’s clinical condition change, you should notify your general practitioner. Changes in your child’s condition or general health may have implications for the timing of your child’s procedure or lead to the clinical priority category being re-assessed.

Due to the high demand on the elective surgery waiting list we aim to book the surgery lists as efficiently as possible. One way you can help us in reducing delays is to ensure you provide us with any updated information. Therefore:

As your child is a patient on the waiting list, you have a responsibility to inform the hospital:

If you decide not to proceed with the procedure for any reason. For example, if the procedure has been conducted at another hospital or you have decided to seek treatment privately or to opt for an alternative treatment

Of any changes to your contact details If you are going to be unavailable for any extended period

The hospital may remove your child from the waiting list in consultation with your specialist if:

The hospital is unable to contact you because you have not informed them of a change in you contact details You fail to present for the procedure without providing the hospital with prior notice You postpone your surgery on two occasions for personal or social reasons

The attached brochure ACT Elective Surgery Access provides additional information about the elective surgery waiting list. Please take the time to read this brochure.

Should you have any questions, please do not hesitate to contact us on the number below.

Yours sincerely

Central Wait List Team Territory Wide Surgical ServicesACT HealthTel: (02) 6205 1122<DATE>




Appendix 11 – Excluded Procedure notification

Patient ID:

<DOCTOR NAME><ADDRESS LINE 1><ADDRESS LINE 2>


Please find attached a Request for Admission (RFA) form for <INSERT PATIENT NAME> received by the central Wait List team on the <INSERT DATE>.

This RFA has not been processed as the proposed procedure has been noted to be listed within the Waiting Time and Surgery Access Policy 2016 as an excluded procedure and is not accompanied with a clinical rationale for the procedure and/or approval from the Director of Territory Wide Surgical Services.

Please return the RFA with the required documentation and approval or contact the Director Territory Wide Surgical Services for further discussion.

Yours sincerely


<DATE>




10 REFERENCES

1. H.G. Beebe, J.J. Bergan, D. Bergqvist, B. Eklöf, I. Eriksson, M.P. Goldman, et al.Classification and grading of chronic venous disease in the lower limbs: a consensus statement. Vasc Surg. 30 (1996), pp. 5-11

2. Canberra Hospital and Health Services - October 2012 Consent and Treatment Policy

3. National Elective Surgery Urgency Categorisation Guideline April 2015 – Australian Institute of Health and Welfare and Royal Australian College of Surgeons

4. Ministry of Health NSW – Waiting Time and Elective Surgery Framework – February 2012

http://www.health.nsw.gov.au/policies/ib/2012/IB2012_....html



http://www.health.nsw.gov.au/policies/ib/2012/IB2012_....html


11 ACRONYMS

AIHW Australian Institute of Health and Welfare

Cat Category

CEAP Clinical-Etiology-Anatomy-Pathophysiology

CEO Chief Executive Officer

CMBS Commonwealth Medicare Benefits Schedule

CPC Clinical Priority Category

DO Day Only

DOSA Day of Surgery Admission

DR Doctor

DVA Department of Veteran Affairs

EDO Extended Day Only

GP General Practitioner

HDU High Dependency Unit

HVSS High Volume Short Stay

ICU Intensive Care Unit

NRFS Not Ready for Surgery

PAS Patient Administration System

RFA Request for Admission

RFS Ready for Surgery

SRD Status Review Date

WC Workers Compensation




12 NATIONAL ELECTIVE SURGERY URGENCY CATEGORY GUIDELINE

CARDIO THORACIC SURGERY

CARDIO-THORACIC SURGERYSelected Common Procedures Usual Urgency Category

Congenital cardiac defect/s 2

Coronary artery bypass grafting 2

Heart valve replacement 2

Lobectomy / wedge resection / pneumonectomy 1

Pleurodesis 2

OTOLARYNGOLOGY HEAD AND NECK SURGERY

OTOLARYNGOLOGY HEAD AND NECK SURGERYSelected Common Procedures Usual Urgency Category

Adenoidectomy 3

Ethmoidectomy 3

Functional endoscopic sinus surgery 3

Laryngectomy 1

Mastoidectomy 3

Microlaryngoscopy 2

Myringoplasty/tympanoplasty 3

Myringotomy 3

Nasal cautery 3




OTOLARYNGOLOGY HEAD AND NECK SURGERYSelected Common Procedures Usual Urgency Category

Nasal polypectomy 3

Nasendoscopy 2

Panendoscopy 1

Parotidectomy/submandibular gland – excision of 2

Pharyngoplasty 3

Pharynx – excision of 2

Pressure equalising tubes (grommets) - insertion of 3

Radical neck dissection 1

Rhinoplasty (indication as noted in Excluded Procedures) 3

Septoplasty 3

Stapedectomy 3

Sub-mucosal resection 3

Tonsillectomy (+/- adenoidectomy) 3

Turbinectomy 3




GENERAL SURGERY

GENERAL SURGERYSelected Common Procedures Usual Urgency Category

Anal fissure – surgery for 2

Axillary node dissection 1

Breast lump – excision and/or biopsy 1

Cholecystectomy (open/laparoscopic) 3

Cholecystectomy (open/laparoscopic) with biliary pancreatitis 1

Cholecystectomy (open/laparoscopic) with potential common bile duct stone or severe frequent attacks (two within 90 days) 2

Colectomy/anterior resection/large bowel resection 1

Fundoplication for reflux disease 3

Haemorroidectomy 3

Herniorrhaphy – femoral/inguinal/incisional/umbilical 3

Lipoma – excision of 3

Malignant skin lesion – excision of +/- grafting 1

Mastectomy 1

Obstructing hiatus hernia (para-oesophageal hernia) 2

Parotidectomy /submandibular gland – excision of 2

Parathyroidectomy 2

Pilonidal sinus surgery 3

Skin lesions (not malignant) – excision of 3

Thyroidectomy/hemi-thyroidectomy 2




GYNAECOLOGY SURGERY

GYNAECOLOGY SURGERYSelected Common Procedures Usual Urgency Category

Bartholin’s abscess drainage 1

Bartholin’s cyst – removal of 3

Curettage and evacuation of uterus 1

Colposcopy 2

Cone biopsy 1

Endometrial ablation 3

Female sterilisation 3

Hysterectomy (abdominal / vaginal / laparoscopic) 3

Hysteroscopy, dilatation and curettage 2

Laparoscopy for dye studies / endometriosis 3

Large loop excision of the transformation zone cervix (LLETZ) 2

Mirena insertion 3

Myomectomy 3

Salpingo-oophorectomy / oophorectomy / ovarian cystectomy 2

Stress incontinence surgery 3

Vaginal repair - anterior / posterior 3

Warts - diathermy of 3




NEUROSURGERY

NEUROSURGERY SURGERYSelected Common Procedures Usual Urgency Category

Carpal tunnel release 3

Cerebral haematoma – evacuation of 1

Cervical discectomy and fusion unless neurological deficit 3

Chiari malformation decompression 3

Common peroneal nerve release 2

Craniotomy for removal of tumour (neurological deficit) 1

Craniotomy for removal of benign tumour(no neurological deficit) 3

Craniotomy for ruptured aneurysm 1

Craniotomy for un-ruptured aneurysm 2

Cranioplasty 3

Discectomy with foot drop 1

Intracranial lesion (for example abscess/arteriovenous malformation) – removal of 1

Laminectomy 3

Muscle biopsy/temporal artery biopsy 1

Nerve decompression of spinal cord 2

Pedicle screw fusion 3

Posterior fossa decompression for haemorrhage, tumour or syrinx 1

Untethering of spinal cord 2

Ventricular peritoneal shunt for obstructive hydrocephaly 1

Ventricular peritoneal shunt for normal pressure hydrocephaly 2




OPHTHALMOLOGY SURGERY

OPHTHALMOLOGY SURGERYSelected Common Procedures Usual Urgency Category

Blepharoplasty (indication as noted in Excluded Procedures) 3

Cataract extraction (+/- intra-ocular lens insertion) 3

Cataract extraction (+/- intra-ocular lens insertion) with angle closure glaucoma 1

Cataract extraction (+/- intra-ocular lens Insertion) with severe disability 2

Chalazion - excision of 3

Corneal graft 3

Dacrocystorhinostomy 3

Ectropion – correction of 3

Examination of eye under anaesthesia 2

Probing of naso-lacrimal Duct 3

Pterygium - excision of 3

Ptosis – repair of 3

Squint - repair of 3

Trabeculectomy 2

Trabeculectomy with high intra ocular pressure 1

Vitrectomy (including buckling/cryotherapy) 2

Victrectomy (including buckling/cryotherapy) with retinal detachment or infection) 1




ORTHOPAEDIC SURGERY

ORTHOPAEDIC SURGERYSelected Common Procedures Usual Urgency Category

Anterior cruciate ligament reconstruction 3

Acromioplasty 3

Arthrodesis 3

Arthroplasty – revision of 2

Arthroscopy 3

Arthroscopy shoulder / sub acromial decompression 3

Bunion (hallux valgus) - removal of 3

Dupuytren’s contracture release 3

Exostosis – excision of 3

Fracture non-union - treatment of 2

Ganglion - excision of 3

Hammer/claw/mallet toe – correction of 3

Meniscectomy 3

Muscle or tendon length – change of 3

Nerve decompression 2

Osteotomy 3

Rotator cuff - repair of 3

Shoulder joint replacement 3

Shoulder reconstruction 3

Tendon release 3

Tenotomy of hip 2

Total hip replacement 3

Total knee replacement 3




PAEDIATRIC SURGERY

PAEDIATRIC SURGERYSelected Common Procedures Usual Urgency Category

Branchial apparatus remnant –removal of 2

Circumcision (indication as noted in Excluded Procedures) 3

Congenital pulmonary lesion – removal of 1

Dermoid cyst - removal of 2

Fundoplication 2

Herniorrhaphy - epigastric/umbilical 3

Hydrocoele – repair of 3

Hypospadias - repair of 2

Inguinal herniotomy/herniorrhaphy for age < 6 months 1

Inguinal herniotomy/herniorrhaphy for age > 6 months 2

Lingual or maxillary frenulum surgery 3

Neonatal surgery (e.g. hirschsprungs, anorectal, malrotation, oesophageal atresia) 1

Nephrectomy for congenital abnormality 2

Orchidopexy 2

Pectus surgery 3

Pyeloplasty 2

Pyogenic granuloma - removal of 1

Skin lesion- excision of 3

Thyroglosssal remnant –removal of 2

Toenail surgery 3

Ureteric - re-implantation 2




PLASTIC & RECONSTRUCTIVE SURGERY

PLASTIC & RECONSTRUCTIVE SURGERYSelected Common Procedures

Usual Urgency Category

Breast prosthesis - removal of (indication as noted in Excluded Procedures) 2

Breast reconstruction (indication as noted in Excluded Procedures) 3

Breast reduction (indication as noted in Excluded Procedures) 3

Cleft lip and palate – repair of 3

Dupuytren’s contracture release 3

Lipoma – excision of +/-grafting 3

Lymphangioma – surgery for 3

Malignant skin lesion – excision of +/- grafting 1

Rhinoplasty (indication as noted in Excluded Procedures) 3

Skin lesions, non-malignant – excision of 3

Scar revision (for reasons other than cosmetic) 3

Trigger finger / thumb release 2




UROLOGICAL SURGERY

* National guideline category changed by Urology Unit Director

UROLOGICAL SURGERYSelected Common Procedures

Usual Urgency Category

Bladder neck incision 3

Circumcision (indication as noted in Excluded Procedures) 3

Cystectomy 1

Cystoscopy 3

Epididymal cyst - removal of 3

Hydrocele - repair of 3

Hyposadias – repair of 3

Lithotripsy 2

Meatoplasty 3

Nephrectomy 1*

Orchidectomy 1

Orchidopexy 3

Prostatectomy (transurethral or open) for benign disease 3*

Prostate biopsy 1

Pyeloplasty 2

Retrograde pyelogram 2

Stone/s urinary tract – removal of 2*

Uretero-pelvic junction - correction of 2

Ureters re-implantation 3

Ureteric stent - insertion of 1

Urethra – dilatation of 2




VASCULAR SURGERY

VASCULAR SURGERYSelected Common Procedures Usual Urgency Category

Abdominal or thoracic aortic aneurysm by any means 1

Amputation of limb 1

Bifurcated aortic graft 1

Carotid endarterectomy 1

Dialysis access surgery 2

Femoro-popliteal bypass graft 2



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